MA (Medical Assistance)    

MFIP (Minnesota Family Investment Program)

Child Care Assistance

Other:                                                      

  SSI received for:                                                                                                                                                                                  

1. Petitioner B
   1. Name and Address:

Full name:                                                             

Prior or other names:                                                       

  No prior or other names.

Street address:                                                           

City, State, Zip:                                                          

2. Has Petitioner B resided in Minnesota for at least 6 months?  Yes     No

If No: 

Is Petitioner B in the military and stationed in Minnesota for at least 6 months?

Yes     No

Has Petitioner B been a domiciliary of this state for at least 6 months?

Yes     No

3. Does Petitioner B receive public assistance or Supplemental Security Income (SSI) for self or children?                Yes     No

If Yes: 

Which type of public assistance does Petitioner B receive?

MA (Medical Assistance)    

MFIP (Minnesota Family Investment Program)

Child Care Assistance

Other:                                                      

  SSI received for:                                                    

 

Information about the Joint Children

1. For each child, give the following information:

Child 1

 Name

Full name:                                                   

 Prior or other names:                                             

 Age:             Date of birth:                              

Child lives with (check all that apply):

Petitioner A

Petitioner B

Other:                                                 

Recognition of Parentage (ROP)

Have Petitioner A and Petitioner B signed a ROP in front of a notary public for this child?                                          Yes                            No

Have Petitioner A and Petitioner B filed the ROP with the Minnesota Department of Health?              Yes                            No

Is there another person who could be this child’s alleged or presumed father?                                                        Yes                            No

 

Child 2  

 Name

Full name:                                                   

 Prior or other names:                                             

 Age:             Date of birth:                              

Child lives with (check all that apply):

Petitioner A

Petitioner B

Other:                                                 

Recognition of Parentage (ROP)

Have Petitioner A and Petitioner B signed a ROP in front of a notary public for this child?                                          Yes                            No

Have Petitioner A and Petitioner B filed the ROP with the Minnesota Department of Health?              Yes                            No

Is there another person who could be this child’s alleged or presumed father?                                                        Yes                            No

 

Child 3

 Name

Full name:                                                   

 Prior or other names:                                             

 Age:             Date of birth:                              

Child lives with (check all that apply):

Petitioner A

Petitioner B

Other:                                                 

Recognition of Parentage (ROP)

Have Petitioner A and Petitioner B signed a ROP in front of a notary public for this child?                                          Yes                            No

Have Petitioner A and Petitioner B filed the ROP with the Minnesota Department of Health?              Yes                            No

Is there another person who could be this child’s alleged or presumed father?                                                        Yes                            No

 

Child 4

 Name

Full name:                                                   

 Prior or other names:                                             

 Age:             Date of birth:                              

Child lives with (check all that apply):

Petitioner A

Petitioner B

Other:                                                 

Recognition of Parentage (ROP)

Have Petitioner A and Petitioner B signed a ROP in front of a notary public for this child?                                          Yes                            No

Have Petitioner A and Petitioner B filed the ROP with the Minnesota Department of Health?              Yes                            No

Is there another person who could be this child’s alleged or presumed father?                                                        Yes                            No

 

Child 5  

 Name

Full name:                                                   

 Prior or other names:                                             

 Age:             Date of birth:                              

Child lives with (check all that apply):

Petitioner A

Petitioner B

Other:                                                 

Recognition of Parentage (ROP)

Have Petitioner A and Petitioner B signed a ROP in front of a notary public for this child?                                          Yes                            No

Have Petitioner A and Petitioner B filed the ROP with the Minnesota Department of Health?              Yes                            No

Is there another person who could be this child’s alleged or presumed father?                                                        Yes                            No

 

Child 6

 Name

Full name:                                                   

 Prior or other names:                                             

 Age:             Date of birth:                              

Child lives with (check all that apply):

Petitioner A

Petitioner B

Other:                                                 

Recognition of Parentage (ROP)

Have Petitioner A and Petitioner B signed a ROP in front of a notary public for this child?                                          Yes                            No

Have Petitioner A and Petitioner B filed the ROP with the Minnesota Department of Health?              Yes                            No

Is there another person who could be this child’s alleged or presumed father?                                                        Yes                            No

 

If there are more than 6 children in this case, use the “Child Information Attachment” (CHC107-Ch) for the other children.

 

Other Court Cases

1. Besides this case, is there any other court case in Minnesota or any other state with Petitioner A and Petitioner B regarding:
   1. Custody?     Yes   No
   2. Parenting time?     Yes   No
   3. Child support?    Yes   No
   4. Child protection?   Yes   No
   5. Domestic abuse?   Yes   No
   6. Harassment?    Yes   No
   7. Other no contact?   Yes   No
   8. Attorney fees, costs,
      disbursements?   Yes   No

If Yes to any of these, give details (for example, court file number, what has been ordered in the case, etc.):                                                                                                                              

                                                               

 

Financial Affidavit for Child Support

1. Financial Affidavit for Child Support (FAM102):

Petitioner A has filled out a Financial Affidavit for Child Support and will include it with this joint petition.

Petitioner B has filled out a Financial Affidavit for Child Support and will include it with this joint petition.

 

Other

2. Other:                                                         

                                                                      

OR

None

 

AGREEMENT OF PETITIONER A AND PETITIONER B
REGARDING CUSTODY, PARENTING TIME, AND CHILD SUPPORT

and

REQUEST FOR COURT ORDER

Petitioner A and Petitioner B ask the court to issue an order that establishes custody, parenting time, and child support according to the parties’ agreement stated below.

 

Custody: Legal and Physical

See Minn. Stat. § 518.003, subd. 3 (https://www.revisor.mn.gov/statutes/cite/518.003#stat.518.003.3).

1. Legal custody means which parent has a say in the major decisions regarding the joint children’s lives, including education, religious upbringing, and medical treatment.

• When a parent has sole legal custody, that parent will be the one to make those decisions. 
• When parents have joint legal custody, both parents have an equal say in the major decisions regarding the children’s lives.

The parties agree that it is in the best interests of the children to grant legal custody of each child as follows:

Name of Child	Grant Legal Custody:
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.

If there are more than 6 children, use the “Child Custody Attachment” (CHC107-Cus).

 

1. Physical custody identifies which parent will handle the routine daily care and control of the joint children.

• When a parent has sole physical custody, that parent will be the one responsible for the daily routine care and control of the children.
• When parents have joint physical custody, the routine daily care and control, and the residence, of the children is structured between the parties.

The parties agree that it is in the best interests of the children to grant physical custody of each child as follows:

Name of Child	Grant Physical Custody:
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.

 

	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.
	Solely to Petitioner A. Solely to Petitioner B. Jointly to both parties.

If there are more than 6 children, use the “Child Custody Attachment” (CHC107-Cus).

 

Parenting Time

1. Parenting time is the time the children spend with each parent. 

The parties agree that the following is in the children’s best interests:

1. Petitioner A’s parenting time with the children shall be:

Unsupervised.

Supervised by                                                       .  The parties agree that Petitioner A’s parenting time should be supervised because:                                                                                                                                                          

Reserved, because:                                     

2. Petitioner B’s parenting time with the children shall be:

Unsupervised.

Supervised by                                                       .

The parties agree that Petitioner B’s parenting time should be supervised because:                                                                                                                                                          

Reserved, because:                                     

3.  Parenting Time Schedules:

Regular Schedule (Monday through Sunday)

                                                               

                                                               

                                                               

Telephone Contact with the Children

  Unlimited

  Only at certain times as follows:                                     

                                                           

Exceptions to the Regular Schedule (if any)

Parents can have a different schedule for summers, holidays, school release days, and birthdays. 

  Summer – The parties agree to follow this instead of the regular schedule:

                                                           

                                                           

                                                           

Holidays – The parties agree to follow a special schedule on the following holidays:

                                                           

                                                           

                                                           

  School Release Days – Includes breaks during the school year:

                                                           

                                                           

                                                           

  Birthdays – Can include children’s and/or parents’ birthdays:

                                                           

                                                           

                                                           

If you need more space for the parenting time schedule, please use the “Parenting Time Attachment” (CHC107-PT).

1. Overnights – Using the schedule from #3c, count the number of overnights each parent has with the children over the course of two years.  Take Petitioner A’s total and divide by 2 to get the average number of yearly overnights Petitioner A has with the children.  Do the same for Petitioner B’s total.  If parenting time is equal, use 182.5 overnights for each parent.

Petitioner A has an average of            overnights with the children each year.

Petitioner B has an average of            overnights with the children each year.

 

Child Support (Basic, Medical, Child Care)

1. Basic Child Support – The parties agree that it is in the children’s best interests that child support be paid as follows (choose a, b, or c):
   1. Payment of Basic Child Support

Who Pays, Amount

Petitioner A    Petitioner B shall pay to Petitioner A    Petitioner B

$            per month as the basic child support obligation for the parties’ joint children.  Any past due amounts from a different court case are still owed.

The party who pays child support is the obligor.  The party who receives child support is the obligee.

Guidelines or Deviation?

The amount is based on the calculations from the child support guidelines worksheet, which is included with this joint petition. 

OR

The amount is a deviation (different amount) from the child support guidelines worksheet, which is included with this joint petition, and:

The children do not receive public assistance.  The reasons for the deviation are:                                                                                                                                            

                                                            

                                                            

  OR

The children receive public assistance.  It would be an extreme hardship on the obligor if the parties do not deviate because:                                                                      

                                                            

                                                            

How Paid

Through income withholding from the obligor’s income, regardless of the source of the income. (NOTE: until income withholding starts, it is good practice for the obligor to make payments to the MN Child Support Payment Center so that there is a record of the payments.  Another option is for the obligor to pay the other parent directly, but then the payment must be reported to the public authority).

If the obligor is self-employed, they should send the basic child support payments to:

 Minnesota Child Support Payment Center
 P.O. Box 64326
 St. Paul, MN 55164-0326

OR

By the obligor directly to the obligee, payable on the        of each month.  (NOTE: if the children receive public assistance, child support payments must be made through income withholding.)

1. Payment of child support will continue as ordered in Court File Number:

                                                                 

 

2. Basic Child Support should be reserved because                                       

                                                                    

                                                                    

Either party can ask the court to order the payment of child support in the future by filing a motion and explaining the change in circumstances.

 

2. Medical and Dental Insurance – The parties agree that it is in the children’s best interests if the court orders the following: 

Medical Insurance (choose a, b, c, or d)

1. Through employer or union

Petitioner A      Petitioner B

shall provide medical insurance for the joint children through their employer or union.  The other party:

must pay $                  as part of the medical insurance costs,

OR

will pay nothing toward the medical insurance costs because they are financially unable to contribute money at this time.

1. Private insurance

Petitioner A      Petitioner B

shall buy private medical insurance for the joint children.  The other party:

must pay $                  as part of the medical insurance costs,

OR

will pay nothing toward the medical insurance costs because they are financially unable to contribute money at this time.

2. Medical Assistance

Petitioner A      Petitioner B

shall pay $                 per month as reimbursement for Medical Assistance, in any month that they are not receiving Medical Assistance for themselves, payable by income withholding through the Minnesota Child Support Payment Center (this option is available only if Medical Assistance is open for the joint children).

3. Reserve the issue of medical insurance for the joint children because:            

                                                                 

 

Dental Insurance (choose a, b, or c)

1. Through employer or union

Petitioner A      Petitioner B

shall provide dental insurance for the joint children through their employer or union. The other party:

must pay $                  as part of the dental insurance costs,

OR

will pay nothing toward the dental insurance costs because they are financially unable to contribute money at this time.

1. Private insurance

Petitioner A   or    Petitioner B

shall buy private dental insurance for the joint children.  The other party:

must pay $                  as part of the dental insurance costs,

OR

will pay nothing toward the dental insurance costs because they are financially unable to contribute money at this time.

2. Reserve the issue of dental insurance for the joint children because:            

                                                                 

 

1. Uninsured and Unreimbursed Medical and Dental Expenses for the Joint Children – The parties agree that it is in the best interests of the children if the court orders (choose a or b):
   1. Petitioner A shall pay        % of the uninsured and unreimbursed medical and dental costs for the joint children.  Petitioner B shall pay                             % (note: the two percentages should total 100%).  The details of the payment arrangement (such as how often the parties exchange receipts, how and when payments are made, etc.) are as follows:

                                                                    

                                                                    

 (NOTE: Parties cannot enforce an agreement to pay uninsured and unreimbursed medical and dental expenses that are more than 2 years old.)

 

2. Reserve the issue of uninsured and unreimbursed medical and dental costs because:

                                                                 

                                                                 

 

2. Child Care Support – The parties agree that it is in the children’s best interests for the court to order (choose a or b):
   1. Petitioner A shall $               per month, and Petitioner B shall pay

$            per month, for child care expenses.

2. Reserve the issue of child care expenses because:                         

                                                                 

 

1. The parties agree that the support obligations (basic child support, medical and dental support/insurance, child care support) will begin on                                                         . 

The parties agree not to ask each other for past child support in this case, or in a separate court case.

 

2. Other Agreement:                                                             

                                                                      

 

I declare under penalty of perjury that everything I have stated in this document is true and correct.  Minn. Stat. § 358.116

 

Dated		Signature of Petitioner A
		Name:
		Address:
County and state where signed		City/State/Zip:
		Telephone:
		Email:

 

 

I declare under penalty of perjury that everything I have stated in this document is true and correct.  Minn. Stat. § 358.116

 

Dated		Signature of Petitioner B
		Name:
		Address:
County and state where signed		City/State/Zip:
		Telephone:
		Email:

 

 

LEGAL REPRESENTATION:

 

Petitioner A’s Attorney		Petitioner B’s Attorney
Petitioner A is:		Petitioner B is:
acting as their own attorney		acting as their own attorney
OR		OR
represented by the following attorney:		represented by the following attorney:
Name		Name
Firm Name		Firm Name
Address		Address
City / State / Zip		City / State / Zip
Telephone		Telephone
Email Address		Email Address
Attorney Registration Number		Attorney Registration Number

PUBLIC AUTHORITY

According to Minn. Stat. § 518.156, subd. 5(c), the public authority must sign this joint petition if any of the parties or children receive public assistance. 

The public authority’s signature is not required.

OR

The public authority responsible for the collection and enforcement of child support reviewed and agreed to the Joint Petition and Agreement of Petitioner A and Petitioner B.

 

 

Dated		Signature
		Name:
		Title:
		Address:
		City/State/Zip:
		Telephone:
		Email:

 

COURT ORDER

 

This case came before the Court without a hearing on the parties’ Joint Petition to Establish Custody, Parenting Time, and Child Support because both parties are represented by attorneys.

 Petitioner A is represented by                                 .

 Petitioner B is represented by                                 .

OR

This case came before the Court for a hearing on                 , at

                                      , in the state of Minnesota.

APPEARANCES

Petitioner A appeared / did not appear in person.

Petitioner B appeared / did not appear in person.

                            appeared as attorney for                            .

                            appeared as attorney for                            .

 

The Court, having reviewed the file ( and having heard from the parties at a hearing), makes the following ORDER:

1. The parties’ Joint Petition and attachments contain the necessary facts and includes an agreement on all issues regarding custody, parenting time, and child support.

 

2. Custody and parenting time are ordered as set out in the parties’ agreement.  The parties are ordered to obey all of its provisions.

 

3. Child support is ordered as set out in the parties agreement, and:
   1. This is a new order for child support.  Both parties have agreed not to ask the other for past child support in this case, or in a separate court case.
   2. Child support will continue as ordered in Court File Number            .
   3. There is a prior child support order; however, this order is now the controlling order.  Arrears under the prior order are still owed.

 

1. Appendix A is incorporated and made part of this final judgment. 

 

Let Judgment be entered immediately.

 

I recommend this Order.			BY THE COURT:
District Court Referee			Judge of District Court
Dated			Dated

 

Judgment

I certify the above constitutes the Judgment of the Court, and Judgment is hereby entered.

 

 

	Court Administrator
Dated: ________________________________________